The operation of couching for cataract is one of the most ancient procedures known to surgery, the earliest description of the method being that given by Celsus, a contemporary of Christ’s. The first historical mention of ophthalmic surgeons was in Alexandria, at the time when medicine and surgery underwent separation from each other in that great and flourishing city, nearly three centuries before the dawn of the Christian era, and Galen states that some of these surgeons devoted themselves exclusively to operating on cataracts. Celsus speaks of the writings of a famous Alexandrian surgeon, named Philoxenes, who lived 270 years before Christ, and from whom he apparently derived much of his lore. These writings have unfortunately been lost, thus yielding to Celsus the proud position of being the first author whose description of the operation has come down to modern times. Sprengel is of the opinion that couching was not only known long before the time of Celsus, but also that the technique of the operation, even at that distant era, varied widely in the hands of its different exponents. Of the correctness of this view there can be little doubt. Sir John Bland-Sutton has recently published a most interesting memoir on the recovery of the sight of Tobit at the hands of his son Tobias, as described in the Apocrypha, and has included in it a copy of Rembrandt’s picture of the famous operation. Whether the displacement of the lens was due to the rubbing employed or to more definite operative measures must be left to speculation, but, in considering this point, it is worth remembering that the Eastern coucher of to-day hides the fact that he is performing an operation under the cloak of the application of a medicinal paste. Nor must we forget that the anointing of the eyes of the blind with clay played a leading part in one at least of the New Testament miracles, and is suggested in a second. It is to be remembered that the Founder of Christianity took His examples from, and moulded His teachings by the aid of things familiar to the people in their everyday life. The influence of the Oriental on the introduction of couching to the Western surgeon is shown by the repeated references in the history of the subject to Eastern exponents of the procedure. Thus, Razes speaks of the work of an Indian named Tabri, and Avicenna, himself an Arabian, describes at length the instruments and technique of the Arab cataract operators. Abu El Kasim’s name proclaims his Arab parentage, despite the fact that he is spoken of as a Spanish surgeon, and the conviction is deepened by the fact that he spoke of the Arabs in Spain as confining themselves to couching in the treatment of cataract, showing he was in intimate touch with them. Nor must we forget to mention the work of Haly Abbas, and of his distinguished son Jesu Haly.

When we endeavour to ascertain the probable date of the first invention of the operation in the East, the fog of uncertainty closes down over us, obliterates all trace of our quest, and drives us to fall back on inference. Those who have spent their lives in an Eastern land know the unbending force of tradition, the hereditary character of occupations, and the intense conservatism of Oriental peoples. All these influences are against change of any kind, and greatly retard the spread of new ideas. When we consider an operation like couching, which is well known over the whole of the East, and which meets in the simplest manner an age-long need, felt in every village of a tropical or subtropical country, it is not difficult to believe that the procedure may have been one of the early fruits of advancing civilisation, far away back in Babylon the Great, or even earlier still in the home of the Pyramids, tens of centuries before the dawn of the Christian era. From these attractive speculations we must return to weigh the literature of our subject, of which the foundation was so well and truly laid by the great Celsus. His description of the technique he employed is as follows:

“Before the operation the patient must use a spare diet. . . . After this preparation he must sit in a light place, in a seat facing the light, and the physician must sit opposite the patient on a seat a little higher; an assistant behind taking hold of the patient’s head, and keeping it immovable, for the sight may be lost for ever by a slight motion. Moreover, the eye itself must be rendered more fixed by laying wool upon the other and tying it on. The operation must be performed on the left eye by the right hand, and on the right by the left hand. Then the needle, sharp-pointed, but by no means too slender, is to be applied and must be thrust in, but in a straight direction, through the two coats, in the middle part betwixt the black of the eye and the external angle opposite to the middle of the cataract. . . . The needle must be turned upon the cataract and gently moved up and down there, and by degrees work the cataract downward below the pupil; when it has passed the pupil, it must be pressed down with a considerable force that it may settle in the inferior part.”

Further details follow. To put the matter shortly in modern terminology, Celsus introduced a needle through the sclera and choroid into the vitreous chamber, and depressed the lens from behind, after first rupturing its posterior capsule by vertical strokes made with the point of the instrument. As already mentioned, Galen (born A.D. 131) states that there were both in Alexandria and in Rome surgeons who confined themselves to operating upon cataract. Apparently he also described his own procedure, for some five centuries later Paulus Ægineta (circa A.D. 630), in detailing his technique, gave Galen the credit for it. There is practically no difference between the method they both employed and that originally laid down by Celsus. A point of real interest in this connection is that the description of the operation given by Paulus is practically the only one extant from the pen of a Greek author, though not a few of them mention couching and advocate it.

For the next landmark in the study of the subject we have to pass over three and a half centuries, till we come to the writings of Avicenna (circa A.D. 980), in which we find introduced a new feature in the technique; for he mentions that the Arab surgeons used two instruments for couching—viz., a two-edged lancet with which they made a corneal incision, and a needle with which they depressed the cataract, after introducing it through the incision thus made. In this needle there was an eye near the point, through which a thread was inserted. According to Avicenna, the object of this was to help depress the lens, but it seems at least possible that the thread passed through this eye was wound round the instrument, and so served as a stop, similar to that used by the Indian coucher to-day. In any case the description is of great interest, linking as it does the Mahomedan operator of the twentieth century with his predecessor of the tenth. The famous Spanish surgeon Abu El Kasim adopted exactly the same technique for couching as that we have just described. This, as has already been suggested, is not in the least remarkable, for his name bespeaks his Arab descent.

The next description of the operation, which claims our interest, is that by Benvenuto (Benevenutus Hyerosolimitamus), who flourished in the twelfth century. The quaint blending of religion and science, which it reveals, makes it very attractive reading: “Towards the third hour, the patient having fasted, thou shouldst make him sit astride of an ordinary chair, and thou shouldst sit before him in the same way. Keep the good eye of the patient shut, and begin to operate on the bad eye, in the name of Jesus Christ. With one hand raise the upper lid, and with the other hold the silver needle, and place it in the part where the small angle of the eye is. Perforate the same covering of the eye, turning the instrument round and round between the fingers, till thou hast touched with the point of the needle that putrid water which the Arabs and Saracens called Mesoret, and which we call cataract. Then beginning from the upper part, remove it from the place where it is before the pupil, and make it come down in front, and then hold it for as long as it takes to say four or five paternosters. After, remove the needle gently from the top part. If it happens that the cataract reascends, reduce it towards the lower angle, and when you have introduced the needle into the eye, do not draw it out unless the cataract be situated in the place described above; then gently extract the needle in the same way as you put it in, turning it about between the fingers. The needle being extracted, keep the eye closed and make the patient lie flat on a bed, keeping him in the dark with his eyes shut, so that he does not see the light or move for eight days, during which time put white of egg on twice a day and twice during the night.”

Passing over four centuries, we come to an even more interesting description of the operation from the pen of Bartisch of Dresden: “The day being decided upon, on which the operation is to be performed, the doctor who is obliged to, or who wishes to do it, must abstain from wine for two days beforehand. The patient must also fast the same day, and must neither eat much nor little till an hour after the operation. Given the aforesaid conditions, try and procure a well-lighted room, in which the patient may have everything necessary for going to bed and remaining there, as he ought not to be taken to any place far off; the nearer to bed the better. Set thyself on a bench in the light and turn thy back to the window. The patient may be seated on a chair, a stool, or on a box, before thee and near to thee; in any case he is to be seated lower than thyself. His legs between thine and his hands on thy thighs. A servant stands behind to hold the patient’s head. The servant should bend a little, so that the patient may rest his head against him (Fig. 1). When the patient is blind of one eye only, the other eye should be bandaged with a cloth and a pad so that he cannot see. Then take the instrument or the needle in one hand, so that the right hand will be for the left eye, and vice versa. With the other hand separate with great care the upper lid from the lower, using the thumb and the first finger, so that thou canst see how to direct the needle into the eye. When thou wishest to introduce the needle, the eye must be turned towards the light and looking straight at thee; also, I should make the patient turn his eye a little towards his nose, so that thou canst use the instrument better and that thou wilt not injure the small veins of the eye, but respect them. Direct the needle straight and with attention over the membrane called the conjunctiva, straight towards the pupil and uvea, at the distance of two blades of a knife from the membrane called cornea or from the grey that is in the eye. Hold the needle quite straight, hold it steady so that it will not deviate or slip. Hold the needle and press it, and turn it with the fingers in the eye with great gentleness, according to the instructions you may gather from the figure, which shows an eye in which the cataract has been taken away, while the other eye has not been touched (Fig. 2). Hold the needle firmly while turning it round, and be careful always to have the point towards the middle of the eye, that it almost touches the pupil and the uvea; and not to oscillate by any chance towards one side. When thou feelest that the needle has penetrated into the eye, that it almost touches the pupil and the uvea, and when thou hast proved to be really in the eye, hold the needle securely and move it, letting it slip backwards and forwards towards the pupil till thou art certain of being in the substance of the cataract, which thou canst easily be sure of by the movement of the cataract material. When thou hast remarked that, lower it carefully and gently and slowly, so as not to disturb the cataract; but try and free the matter entirely from the pupil and from the uvea with care, and keep it intact. Press the said matter with the needle under it, with the greatest care, and when thou perceivest that it is altogether free and loose, draw and direct the needle, with the matter behind it, upwards, and then pass it well downwards, behind the thin retina and the aranea of the eye; and take care that it remains there. . . . This is the recognised instruction, research, and indication of the means of operating, of pricking the cataract, or of the manner in which such an operation ought to be initiated and conducted. But no one ought to undertake such an operation unless he has learnt much and seen much, and unless he is fundamentally taught by intelligent doctors. Unless he is so, it is not well to operate. And it is not wise to trust to any of the brotherhood who happen to be dressed in velvet or silk, and who boast of being great oculists, and are capable of curing the blind from cataract. Certainly these can make holes in the eyes, but I do not know how they can succeed.”

The knowledge which the Greeks and the Arabs possessed, before and after the dawn of the Christian era, on the subject of the pathology and treatment of cataract, appears to have been largely forgotten during the Middle Ages. It would seem that both couching and extraction fell into disuse, and that the surgical treatment of cataract was left for centuries in the hands of wandering charlatans, whose ways brought much discredit upon it. Towards the close of the seventeenth century, Pierre Brisseau, a doctor of Tournay, revived the operation, inventing a needle of his own for the purpose. His advocacy of the method aroused bitter controversy, but it was undoubtedly the best operation in the field until the famous French surgeon Daviel performed his first extraction in 1745, and thus sounded the death-knell of a procedure which had held the pride of place in European surgery for over seventeen centuries. It was, however, many years before couching was definitely abandoned in favour of extraction. Indeed, the author has recently had the privilege of discussing this subject with a distinguished surgeon, who can remember the time when depression was still a recognised method of operating in London. It is a great mistake to suppose that Daviel was the first to endeavour to extract a cataract, for both extraction and suction of cataracts have their roots far back in history. Indeed, Antyllus described his method of extraction at the close of the first century of the Christian era, and there are numerous other references to it in early literature. What Daviel did was to adopt a technique which gave a reasonable prospect of success.

The introduction of reclination, as opposed to depression, by Willburg in a Nuremberg thesis, dated 1785, gave a fresh lease of life to couching in its dying struggle with the operation which was destined to supersede it. England, France, Sweden, Germany, and other countries, joined vigorously in the discussion, and amongst the powerful advocates of couching were ranked Percival Pott and William Hay of London, Cusson of Montpellier, and Scarpa of Pavia, whilst Benjamin Bell practised both couching and extraction. The admirable treatise by James Ware on cataract (1812) was all but a death-blow for Celsus’s operation. The newer procedure was then well in the ascendant, and only needed time to completely strangle its rival. Notwithstanding this, it was left to Mackenzie, so late as 1854 (fourth edition), to give the most complete and interesting description of couching to be found in literature. He distinguishes sharply between the operations of depression and reclination. In depression, the lens is pushed directly below the level of the pupil, being made to follow the curvature of the eye, to sweep over the corpus ciliare, until it comes to rest on the lower curve of the eyeball, with its anterior surface directed forward and downward (Fig. 3). In reclination, the lens is made to turn over towards the bottom of the vitreous chamber in such a way that what was formerly its anterior surface now comes to look upward, and what was its upper edge is turned to the rear. The whole lens is swung backward as if on a hinge, composed of the lower fibres of its suspensory ligament, which still remain unbroken (Fig. 4).

He divides the operation of couching into four stages, in only the last of which reclination differs from depression. These are: (1) the pushing of a special needle (Fig. 5) through the coats of the eye at a distance of  1/6 inch behind the temporal edge of the cornea, and to a depth of  1/5 inch; (2) the laceration of the posterior capsule of the lens by vertical movements of the point of the needle, to prepare an aperture for the passage of the lens; (3) the passing of the needle into the anterior chamber around the edge of the lens, and the laceration of the anterior capsule by vertical strokes; (4a) to depress the lens, the point of the needle is carried over its upper edge, and the handle is raised a little above the horizontal, thereby correspondingly lowering the point, which forces the cataract downward out of sight behind the pupil: the needle is then withdrawn by rotation; (4b) to effect reclination, the needle-point is raised not more than  1/10 inch above the transverse diameter of the lens: its concave surface is pressed against the cataract, which is reclined by moving the handle of the instrument upward and forward, thereby causing its point to pass downward and backward. The cataract is thus made to fall over into the vitreous humour, and is then pressed downward, backward, and a little outward. Mackenzie adds many interesting details as to the modifications of the operation, according to the variety of the cataract to be dealt with, and as to the after-treatment and complications met with.

We come now to a very interesting phase in the study of the operation of couching. We have shown reason to believe that, like many another valued heritage of the West, it was brought there originally by Wise Men of the East. For more than eighteen centuries it remained a treasured possession of surgery, only to yield its ground before the fierce competition of a method better able to survive the stern test of experience. Slowly but surely its decadence banished it from modern scientific European literature, and then, strangely enough, the advent of Listerism fanned the dying flame of interest in the method; but this time in the East, and not in the West. From the East it had sprung to find a home in the West, and in the East, at the hand of Western surgeons, its last, and by no means least, interesting chapter is in the course of being written. A review of the more recent literature on the subject will establish this contention, and will show how large a share the officers of the Indian Medical Service have taken in the settlement of a question which, apart from its scientific value, has important social and even political bearings.

After a brief visit to India, Hirschberg, in 1894, published an article on couching, in the course of which he spoke favourably of the results of the operation. He was, unfortunately, handicapped by his ignorance of the natives of India and of their ways and customs, with the result that his views on the subject are of comparatively little interest to us. In the following year Captain H. E. Drake-Brockman described the operation of couching as explained to him by one of its Indian exponents. The latter pierced the sclerotic with a small lancet in the lower outer quadrant close to the cornea, and then introduced a copper needle; “a series of motions of the hand are made from the position on first introduction of the needle to a point corresponding to it in the upper section of the outer diameter of the eyeball.” The depression of the lens appears to have taken place next, but the description is throughout somewhat vague. Presumably the operation was the same as that described by Ekambaram, but the coucher does not seem to have been able to make the steps of the procedure as clear as that surgeon has done.

Henry Power, in the British Medical Journal (October, 1901), entered a plea for the occasional performance of the operation of depression in cases of cataract. His experience went far enough back to enable him to remember the time, not only when he had seen surgeons of repute employ this method, but when he had himself imitated the example thus set. His own practice had been to attack the cataract, via the sclerotic, through the posterior capsule. He framed a number of indications which to his mind justified the occasional performance of couching. It is safe to say that very few of these would be seriously entertained by surgeons to-day. The most interesting point he made was in connection with Himly, in whose work, published in 1843, the statement occurred that “severe inflammation rarely followed reclination, and when it did it often cleared up without leaving any bad consequences.” A doubt as to the reliability of Himly’s statements is suggested by his claim that he had only two failures in fifty cases, one of these not being attributable to the operation. This is so much at variance with the experience of others as to make one sceptical about accepting any of his assertions without some reservation.

The next paper of value that we come to is by Maynard (1903). In this he analysed sixty-three cases of couching, which he had met with in Indian practice, and recorded the anatomical examination by Parsons of a couched eye sent home for the purpose. The same year saw the appearance of a paper by Albertotti of Medina, in which that writer somewhat fanatically and unconvincingly advocated a return to couching, with the use of a corneal puncture and with the employment of special instruments for the purpose. A year later he was followed along the same lines by Basso of Genoa, whilst Quartillera published a paper whose recommendations were very similar to those made by Henry Power. In 1905, Major Henry Smith of Jullundur, in a very outspoken article in the Indian Medical Gazette, expressed the opinion “that lens couching at the present time is an operation which should not be practised outside the ranks of charlatans,” and added that “it is no easy matter to completely dislocate the lens, and in my observation the partial dislocation is more frequent than the complete in the hands of adepts of the art.” In reply to this paper, Maynard reaffirmed his belief that couching is “justifiable under certain conditions.” The editor of the Indian Medical Gazette invited further discussion of the subject, and in accordance with this request the writer published his statistics based on 125 cases of couching, carefully recorded on printed schedules. In the course of that paper he voiced his strong opposition to the adoption of the Indian operation, or of any modification of it, in the hands of surgeons who enjoy the unique opportunity of obtaining manipulative skill granted to those who work in India. A former pupil of his, Dr. Ekambaram, studied the ways of the Indian coucher at first-hand, and gave the results of his experience in one of the most valuable contributions to the subject yet made. This was in 1910. Two years later the writer was able to review the statistics of 550 consecutive cases of couching, all of which had been carefully noted. Still more cases accumulated before he left India, and by the kindness of Major Kirkpatrick, the total under review has now reached 780.

The examination by J. H. Parsons of a couched eye has already been mentioned. In 1913, A. C. Hudson sectioned and described a similar specimen sent him from India by the writer. The only previous published records of the same kind are from the pen of E. Treacher Collins, and refer to four specimens of couched eyes in the Museum of the Royal London Ophthalmic Hospital. Major H. Kirkpatrick has recently examined several more cases in Madras, and has kindly communicated some of the more interesting of his findings to the writer. Communications, that have been made from time to time before meetings of ophthalmologists, show that British surgeons of the first rank are still in favour of performing couching under certain special conditions. A marked instance of this is to be found in the discussion which took place before the Ophthalmological Society of the United Kingdom on February 8, 1906, following the presentation of a case by Holmes Spicer. On that occasion Rockliffe and Treacher Collins stated that, like Spicer, they had performed the operation in exceptional cases, and Devereux Marshall and G. W. Roll accorded it a modified support under such conditions. The writer has also learnt from personal communications that other leading surgeons have taken a similar line. There for the present we must leave the history of this operation, whose origin is lost in the dim mists of antiquity, and whose chequered career forms one of the most interesting pages in the literature of medicine.

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